Sutureless Conjunctiva-Sparing Müllerectomy

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Abdulrahman Almalouhi, Frank.Mei, Ronald Mancini

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Ronald Mancini

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Introduction

Sutureless conjunctiva-sparing Müllerectomy (CSM) is a posterior approach to blepharoptosis repair in which the palpebral conjunctiva is dissected free and preserved rather than excised. The underlying Müller muscle and levator is plicated by mechanical crush followed by bipolar cautery, no suture is placed, and the conjunctival flap is returned over the operative bed without fixation

Posterior approach ptosis surgery has evolved through successive modifications, each declining to sacrifice a tissue that the preceding technique removed . The

Fasanella-Servat procedure excises a segment of tarsus along with conjunctiva and Müller muscle . Müller's Muscle-Conjunctival Resection (MMCR) described by Putterman and Urist in 1975, spares the tarsus but removes anatomically normal conjunctiva and leaves suture material in contact with the posterior eyelid surface . Postoperative discomfort attributable to suture on the palpebral conjunctiva has been described as a recognized limitation of the procedure .

Figure 1) Eyelid eversion and placement of the Desmarres retractor’s blade

Figure 2) Subconjunctival Lidocaine injection with hydrodissection.

Figure 3A) Conjunctival dissection using blade, with the incision tracing the superior edge of the tarsus, B) spanning almost its entire length. C) Relaxing incision with Westcott scissors.

Conjunctival preservation during posterior ptosis repair has been described in isolated Müller muscle resection and in anophthalmic ptosis repair .

Conjunctiva-sparing Müllerectomy as the term is used here was described in 2016 in 18 patients and 30 eyelids . The conjunctiva is incised at the superior tarsal border and dissected off Müller muscle, which is then sutured and excised as in MMCR, and the flap is replaced so that healing conjunctiva covers the suture . The sutureless modification replaced excision and suture fixation with crush and cautery plication .

Candidate selection mirrors that for MMCR: mild to moderate ptosis with good levator function . As with MMCR, eyelid elevation is attributed to plication of the Müller and levator complex rather than to the volume of tissue removed .

Indication

Sutureless CSM is indicated for mild to moderate blepharoptosis with good levator function, generally 10 mm or greater, and a positive phenylephrine response . Patients with poor levator function require other approaches, including Levator advancement/resection and Frontalis suspension. Candidacy otherwise parallels that for MMCR.

The technique is especially suited to patients whose conjunctiva is already compromised or may be needed for future surgery: younger patients, patients with ocular surface disease, patients with ocular hypertension or glaucoma who may need filtering surgery in the future, and anophthalmic patients, in whom fornix depth must be preserved for prosthesis wear .

Children are appropriate candidates when levator function is 10 mm or greater and, where cooperation permits, phenylephrine testing is positive. The absence of suture is a particular advantage in this group, avoiding suture-related discomfort and the need for suture removal, and the shorter operative time reduces anesthesia exposure .

Untreated myasthenia gravis and any history of cicatricial conjunctival disease are clinical contraindications, the latter because the risk of disease reactivation and the operation depends on raising a healthy, dissectable conjunctival flap. Prior ptosis surgery, recent trauma, and recent cranial nerve palsy were excluded from the published series to establish a uniform cohort, but do not in themselves preclude the technique .

Phenylephrine test (PE test)

Most surgeons individualize posterior ptosis repair to the phenylephrine response: in a national survey of ASOPRS members, 55.6% varied the resection by phenylephrine response, 46.5% by the amount of ptosis, and 13.2% used a standard amount [11]. Protocols vary, and the general technique and interpretation of the test are covered in the Müller's Muscle-Conjunctival Resection (MMCR).

As applied to Sutureless CSM:

1. Measure baseline MRD1 before any drops are instilled.

Figure 4A) Conjunctival flap is grasped with fine-toothed forceps and B) the conjunctiva sharply dissected free of Müller muscle using blunt-tipped Westcott scissors

Figure 5) Exposure and separation of Müller muscle with blunt dissection with a cotton-tipped applicator.

2. Have patient look down and place two drops of phenylephrine 2.5% in the superior fornix.

3. Re-measure MRD1 after ten minutes.

The measured response sets the planned plication through a nomogram modified from the original MMCR description. A response to the desired height calls for an 8 mm plication. Each 0.5 mm of undercorrection adds 1 mm; each 0.5 mm of overcorrection subtracts 1 mm. The total ranges from 4 mm to 10 mm .

Planning should not rely on the traditional 4:1 resection-to-elevation ratio. In the reported series, achieved elevation averaged about 1 mm more than the ratio predicts.

During the test, observe the contralateral eyelid and discuss the findings with the patient. Elevation of a ptotic eyelid can unmask contralateral ptosis through Hering's law of equal innervation, a response demonstrated after unilateral ptosis repair .

The test also doubles as patient education. A hand mirror at the ten-minute mark gives the patient a preview of the expected result and helps distinguish what ptosis repair will address from what would require blepharoplasty or brow surgery.

Surgical Procedure

Recommended Instruments:

• Dermar retractor
• #15 blade
• 2x 0.5 forceps
• Blunt tip westscott
• Fine straight hemostat
• Bipolar
• Several forceps configurations can deliver the energy. Standard bayonet and angled-tip bipolar forceps are effective. Bipolar forceps have also been designed for this application to have an elongated tip that spans the width of Müller muscle and follows the curve of the tarsus.

Surgical Planning and tips:

Figure 6) Freed conjunctival flap rested on the skin of the lower eyelid.

Figure 7) Isolation of the grasped Müller muscle.

The length of Müller muscle to be plicated is determined preoperatively from the response to phenylephrine testing, using a nomogram modified from the original MMCR description. If phenylephrine raises the eyelid to the desired height, an 8 mm plication is planned. For every 0.5 mm of undercorrection, 1 mm is added; for every 0.5 mm of overcorrection, 1 mm is subtracted. The planned plication ranges from 4 mm to 10 mm.

Sequencing with concurrent procedures:

Unlike MMCR, in which blepharoplasty may be completed after the ptosis repair, the unfixated conjunctival flap is vulnerable to displacement. When multiple upper eyelid procedures are performed, ptosis repair is recommended to  be completed last, minimizing the risk of dislodging the flap or stretching the developing adhesion.

Steps:

Step 1: Exposure

Topical anesthetic drops, such as tetracaine, are instilled. The eyelid is then everted over a Desmarres retractor with the retractor’s blade seated at the superior tarsal border. (Figure 1) Gentle downward pressure on the retractor’s handle torques the tarsus and places the overlying conjunctiva under tension. Excessive force should be avoided, as it risks further disinsertion of the levator aponeurosis.

Step 2: Local anesthesia

With the eyelid everted, lidocaine 1% with epinephrine 1:100,000 is injected subconjunctivally. Beyond anesthesia, the injection delineates the plane of dissection and limits bleeding from the well-vascularized Müller muscle. Volumes under 0.5 mL per eyelid reduce the risk of chemosis, and symmetric volumes should be given bilaterally. (Figure 2)

Step 3: Conjunctival incision

A #15 blade incises conjunctiva alone along the superior tarsal border, spanning nearly its full length. (Figure 3A,B) Care is required to avoid disinserting the underlying Müller muscle; appropriate tension on the retractor helps regulate incision depth. Relaxing incisions are then extended superiorly from each end of the initial incision, or equivalent back-cuts may be made with Westcott scissors. (Figure 3C)

Step 4: Flap dissection

The retractor is handed to the assistant. One corner of the conjunctival flap is grasped with fine-toothed forceps, and blunt-tipped Westcott scissors are used to sharply dissect the conjunctiva off the underlying Müller muscle. The dissection proceeds along the superior edge of the tarsus toward the opposite corner of the flap. (Figure 4 A,B)

Figure 8) Fine straight hemostat forceps creating a crush zone within the tissue of Müller muscle.

Once both corners are free, the surgeon holds one and the assistant the other. Pulling the conjunctiva upward places the tissue on stretch and reveals adherent bands of Müller muscle. If the muscle is tightly adherent, rolling a cotton-tipped applicator against it helps separate muscle from conjunctiva and brings the bands into view. (Figure 5)

Dissection then continues superiorly until the intended length of muscle is exposed. The freed conjunctival flap is reflected downward and rested on the skin of the lower eyelid. (Figure 6)

Step 5: Isolation of Müller muscle

The predetermined length of muscle is grasped with forceps, one end held by the surgeon and the other by the assistant. The forceps are held closer together than they would be in MMCR, because without its overlying conjunctiva the isolated muscle tends to sag. The assistant removes the Desmarres retractor. Pressing downward on the tarsus with a cotton-tipped applicator further isolates the grasped muscle and defines it against the tarsal border, in preparation for the crush. (Figure 7)

Step 6: Mechanical crush

Fine straight hemostat forceps are applied with firm pressure to create a crush zone within the tissue (Figure 8) and leave a visible imprint marking the extent of the intended plication. (Figure 9)

Step 7: Cautery plication

Bipolar cautery is applied to the crushed tissue, working down to the superior tarsal border, and the tissue is allowed to contract. The conjunctiva and the tarsus must be shielded from the cautery throughout. (Figure 10)

The completed plication extends anteriorly beyond Müller muscle to involve the levator aponeurosis. When blepharoplasty is performed at the same sitting, this involvement can be seen directly from the anterior side.

Step 8: Flap replacement

The conjunctival flap is laid back over the plicated tissue (Fig 11) and the eyelid returned to its normal position. No suture is placed; the flap is retained by adhesion alone.

Figure 9) Post tissue crushing with visible imprint marking the extent of the intended plication.

Figure 11) Conjunctival flap laid back over the plicated tissue.

Figure 10) Bipolar cautery placement on crushed tissue in preparation for cautery.

Procedural steps can be viewed in the video.

Post-Op Care

Postoperative care varies among surgeons and institutions. Antibiotic ointment can be prescribed. Patients should be counseled to avoid rubbing or manipulating the eyelid. At one week the flap should appear well positioned and perfused .